Preparing Head Start/Child Care and Communities for Seasonal Influenza

Preparing Head Start/Child Care and Communities for Seasonal Influenza

Sean Dietrick: Welcome, and thank you for standing by. My name Sean Dietrick, and I'm a program manager for Disaster Preparedness and Response Initiatives at the American Academy of Pediatrics. I'm pleased to welcome you to today's National Center on Early Childhood Health and Wellness webinar. The webinar today will describe recommendations for this year's influenza season -- discuss why it's important for everyone who works in Head Start, or other child care programs, to be vaccinated for flu -- and share strategies that can be used in child care settings to prevent or control the spread of influenza. The webinar will also explore ways to prepare for an unlikely, but dangerous, flu pandemic. Before we begin the presentation, I have a few announcements. All participants will be muted throughout the presentation portion of the webinar. There is a slide presentation being shown through the webinar system. If you have a technical question, please type in the chat feature of the webinar, call 1-800-843-9166, or email support at readytalk.com. There is a lot to cover within the next hour and a half. You may submit your questions at anytime by typing in the webinar chat box feature. Only you and webinar staff will see your question.

We will answer some questions right away. For any questions that we do not have time to cover, we will answer those via email after the webinar. At the end of the presentation portion of the webinar, there will be a moderated question and answer session. Immediately following the webinar, you'll be prompted to take a brief evaluation. Only those who complete the evaluation questions will receive a certificate of participation. The certificate will be emailed to you by January 25th. The webinar is being recorded, and an archive version, along with the slides, will be available. For today's session, we have two experts speakers. Our first speaker, Dr. Flor Munoz, is an associate professor of Pediatrics at Baylor College of Medicine, and pediatric infectious diseases consultant at Texas Children's Hospital in Houston, Texas. Dr. Munoz has been a member of the American Academy of Pediatrics' Committee on Infectious Diseases since 2015. Dr. Munoz is also the AAP Committee on Infectious Diseases representative for the Influenza Working Group of the Advisory Committee on Immunization Practices, or ACIP. Her research interest is in respiratory pathogens and vaccine-preventable diseases, as well as vaccines for children and maternal immunization.

Our second speaker, Dr. Timothy Shope, is an Associate Professor of Pediatrics at the University of Pittsburgh, School of Medicine. He has retired from the Navy in 2011, where he served as a childcare health consultant for the Navy's Mid-Atlantic region for the Department of Defense for 10 years. He also served on the American Academy of Pediatrics Executive Committee of the Section on Early Education and Child Care. He is the co-editor of the AAP manual Managing Infectious Diseases in Child Care and Schools, fourth edition, a technical panel chairperson for Caring For Our Children, third edition, and is the co-author of two online curricula about managing infectious diseases and early education in childcare settings. Before I turn the presentation over to Dr. Munoz, I wanted to inform our participants that we will have several polling questions scattered throughout the presentation. As soon as these questions appear on your screen, feel free to answer the question as you see fit, and click the Submit button. Your response to the question will remain confidential. I would now like to turn the presentation over to Dr. Flor Munoz.

Dr. Flor Munoz: Thank you, Sean, and good afternoon, everyone. I appreciate the opportunity to talk with you today about a very important topic that is critical for the next few weeks. And I would like to start with trying to see if we can understand why our children are at particular risk for infectious diseases, and talk about influenza in that context. We know that young children have immune systems that are still developing, and, therefore, they might not be able to respond well to certain infections while they are being exposed to many germs during their daily activities. As you know, young children will have many opportunities to share everything, including their germs, as they go about their day.

And caregivers, and some children in particular, don't always necessarily know about washing hands, or they don't do it routinely, after touching their nose, eyes, mouth-- or before eating, playing, and touching each other. We also know that young children might not be as good with cough etiquette, and cover their cough the way we're supposed to teach them how to do. And they might not be able to get vaccinated, some of them, because they are too young-- for example, children under six months of age. We also know-- and we do this often, unfortunately-- they don't always stay home when we are ill. And especially, this is true for young children who might not present all the symptoms quite obviously until later on, but yet they could be able to transmit the viruses early in their illness. So why should we worry about the flu? We know that influenza happens every year. And we hear about it often -- as early as the fall. And there are many ways by which we can look at the burden that influenza has in our community, and in our country every year. Certainly, when you look at this pyramid, you can see that the deaths that occur, and the hospitalizations that occur every year associated with influenza, are the tip of the iceberg-- or the tip of this pyramid. Yet, we have anywhere from 3,000 to almost 50,000 people who die of influenza every year, depending on the season, and anywhere between 100 to almost 800,000 hospitalizations that occur. This is not an insignificant number.

If you look at the rest of the pyramid, influenza results in millions of doctor visits every year for illnesses that go from a fever, to more severe complications of influenza. And certainly, the people who are actually infected and become ill with influenza, are anywhere between 50 and 60 million every year. So 10 percent to 20 percent of the population can become sick with influenza every year during the routine, regular influenza season. It's a very significant disease. This slide shows you where we are this year, in the 2017-2018 season. And these are graphs that are put out by the CDC. In the map, you can see the level of influenza-like illness activity, where the red is the highest level of activity. And as of the end of December, in the middle of the holidays, you can see that most of the country was in a high level of activity as influenza was spreading throughout the country. We are probably at this point in January, at the peak of the season in many places in the United States. The insert graph that you have at the bottom right, shows you the number of influenza-positive tests that are reported to the CDC, by laboratories around the country, where influenza testing is performed. And this matches the activity that we are seeing every year, where you have an increase in the number of tests that become positive as more people become tested. And you see that the peak is being reached at the end of December.

At the same time, you can see in this graph that the different colors are representing different strains, or types, of influenza, that we see circulating in the community. There are usually influenza A influenza B viruses. And there are at least two types of influenza A, and two types of influenza B, that circulate around the country. You see that the red bars represent the majority of influenza that we are seeing this year is influenza A, and it is of that type of H3N2 influenza. Here is a question for you. And this is your first poll. So let's read it together, and you can start answering right now. But I will stop the poll in a few seconds after we finish reading it. Which combination best describes a common presentation of the flu? Is it cough, chills, and spots on the throat? Is it red, itchy skin rash, chills and headache? Is it headache, fever, vomiting, and diarrhea? Or is it cough, fever, sore throat, and body aches? I'm going to give you a few seconds. Very well. I will go ahead, and go to the results to see where we are. Thank you for all of you who answered. And you can see that the vast majority -- 93 percent of you indicate that a common presentation of the flu is cough, fever, sore throat and body aches. Absolutely correct.

Now, there are other symptoms that you can see with influenza. And I am going to show you those here. The flu -- what we call the flu -- is actually a viral infection of the respiratory system -- so your breathing system. That involves the nose, the throat, the lungs. And as we have seen, it causes annual epidemics. So we all might be susceptible every year. And the symptoms that you can see associated with the flu, typically, those are the two classic ones -- sudden fever, and a dry, hacking cough. The two at the very top. But it doesn't stop there. It certainly is a systemic illness in the sense that not just your respiratory system will be having symptoms, you will also have headaches, and body aches, and chills, in addition to the sore throat, and the stuffy nose. People will feel very tired, with much less energy. And then other symptoms that we see, especially in young children, include nausea, vomiting, and diarrhea, and abdominal pain-- belly pain, which actually can cause dehydration. And this is part of why some of these children end up in the hospital. But then you can have pinkeye. And these are the very common symptoms.

There will be other complications that we can see with influenza, that include pneumonia, and even central nervous system symptoms as well. So what about contagiousness? Turns out that influenza is one of the most contagious infections that we have out there. And these just some numbers. So if you look at the incubation period of influenza, it is stated to be about one to four days. So that means after you have been next to, or around a person who has the flu, and you catch it, in about one to four days you'll be sick as well. And actually, the average is about two days. So the majority of people who get influenza, it is because they were around somebody with the flu about a couple of days before. So it spreads very quickly, and it makes you sick very quickly. And what is important is that the contagious period of influenza actually begins before the symptoms appear. So for one whole day before you start having fever, or before you start having headaches and body aches, you could also already be having a virus replicating in the nose, and then spreading the virus to others. And this spread, this contagious period, lasts about a week after the onset of the first symptom. So that, because of viral shedding -- which is the shedding of the virus through your nose, or saliva -- you will be able to transmit this virus to other people. And so, this is actually more important even in children, because the viral shedding is more prolonged in children.

They tend to have a lot more virus, and shed it for longer time. So both adults and children then spread influenza when they are infected, but not yet showing signs of the illness. That's your incubation period. Also, when they have symptoms, and when they are recovering from the illness, because of this virus shedding. You can see how important influenza is, in terms of potentially causing outbreaks in the communities. And the other piece that I wanted to make sure everyone takes home as an important message is that children are the primary vectors of influenza. They do play a pivotal role in the transmission of influenza every year during the outbreaks. I have them here in the center of this circle -- especially children who attend childcare, preschool, and all those children who go to school. Because they, again, have many opportunities to be around other children. So they transmit the virus to other children. They transmit it to their family members. And so other family members can get it from the children as they come home. And this circle is then closed when you see transmission to other members of the community by the children, or other family members as well-- especially high risk populations. And this is something that has been described for decades. We know about the role of children since the 1970s.

So in summary, flu is different from a cold. And, yes, they're both caused by viruses, but influenza, in terms of the symptoms that it causes, is definitely more intense. It's not just a runny and stuffy nose. It actually causes fever, body aches, and more symptoms, as we have described. In addition to that, we can see -- and we will talk a little bit about this -- how influenza can lead to hospitalization or death, which is not commonly seen with other cold viruses. We also have a way to prevent influenza, because we have vaccines that are available. And we have ways to identify influenza by doing it test, and knowing exactly that this is the case-- that influenza is what the patient has. So let's look at, then, these complications. Who is really at high risk for influenza complications? This graph looks a little bit complicated itself, but let me walk you through it. It's put out by the CDC every year. And in this case, I am showing you the 2016-2017 influenza season -- so the previous season, not the current one.

You have on your left side a list of the number of potential underlying medical conditions that people could have, that would make them have increased risk for influenza. And on the x-axis you have the proportion, or the percentage of people, who have these conditions, that are hospitalized with influenza. I'll take you all the way down to the bottom of the graph, and you can see that the bars in green represent the children, and the bars in blue represent the adults. For children who are hospitalized with influenza, half of them-- so 50 percent of them were previously healthy. So there had been no underlying conditions that were recognized in the 50 percent of children who end up in the hospital during the 2016-2017 season. But this is actually quite consistent every year, and with CDC data, as we can see. And then you can see the other underlying conditions, especially for children, the most important medical condition is asthma-- 21 percent of those hospitalized. Neurologic disorders at 18 percent. So what is this? This is our patients with potentially problems with swallowing, or that have high risk of aspiration. So children who have seizures, or cerebral palsy, or any other type of neuromuscular problem that doesn't allow them to swallow and protect their airway well. And the third one is chronic lung diseases of other types. So, again, I just want to point out that although we focus a lot on medical conditions, the fact that children who are healthy are hospitalized is important. And it is a great part because of their age.

Young children tend to be at greater risk just because of their age, even if they are healthy. Another interesting statistic that comes out from the CDC is in terms of hospitalizations. And I'm showing you here the previous five seasons, and also the 2016-17 season. So six seasons in total. And you have the rate per 100,000 population who is admitted to the hospital. On the x-axis-- the time during the year. So it's accumulative admission during the season. And I just want to point out to you that, in terms of risk, young children zero to four years of age-- again, the majority of whom will be healthy -- have a very similar, and sometimes higher risk of hospitalization, and rates of hospitalization, than people who are in their 50s and 60s, which is a high risk population, as we know. And lastly, another way of measuring the burden of influenza, is to look at the mortality. So this shows the current season 2017 and '18 to your far right. And then you can see the previous three seasons, where influenza mortality has been reported in children. And it is not an insignificant number when you think about it. At least 100 children or more can die every year, just from influenza in the United States. We have already had 13 cases of mortality associated with influenza reported this year. And I want to point out that these are those that are reported. So many times they are actually confirmed. There's probably more mortality associated with influenza, that does not make it to the reporting. And for a vaccine-preventable disease, especially in children, this is not acceptable. So let's look at the recommendations. What can we do about this?

There are recommendations in place that get updated every year, so the 2017-2018 Influenza Prevention Recommendations that are put out by the CDC, Centers for Disease Control and Prevention, through the Advisory Committee of Immunization Practice and the American Academy of Pediatrics, are all concordant-- so in agreement. And they are supported by a number of organizations, including the American Academy of Family Practitioners, and ACOG, which is obstetrics and gynecology. And their recommendations are simple. Basically everyone, starting at six months of age, needs to get their flu vaccine. And why starting at six months of age? It's because we don't have a vaccine for babies under six months of age. And why everyone? Because as I mentioned, we are all potentially at risk for influenza, regardless of our age and of our health status. There are some populations that we are particularly interested in reaching though, for vaccination. We've talked already about children. Persons over 65 years of age-- Pregnant women are an important population, because just pregnancy, in and of itself, increases their risk to have complications from influenza. And then those with underlying medical conditions, as we have mentioned before, including persons with asthma, and a number of other medical conditions as you see listed in the slide. Finally, health care personnel. Household contacts, and caregivers of any high-risk individual, and children need to be vaccinated in particular. And this is a recommendation that is emphasized every year. So when should we get vaccinated? Certainly the vaccine becomes available, usually, early in the fall. So end of August, September for the most part. And it is important to start vaccinating as soon as possible, as soon as the vaccine is available. Certainly no later than the end of October.

And the reason is because we need time to have full protection. And we don't know exactly when the flu will start circulating in the community. This year, for example, in 2017, we started seeing influenza as early as Thanksgiving time. So by early December, we already had influenza. Many times we don't see it until January or February, but sometimes we see it as early as October. So we just need to be ready. And this recommendation is to try to make sure that the two weeks needed for influenza vaccine to be effective are taken into consideration when you get your shot, so that once influenza is out there, you would have already had your vaccine. And then we want to continue to vaccinate until late in the spring, because there is a potential that one can get influenza more than once, or that we can have activity with different strains during the flu season. So, even if you haven't been vaccinated yet, we still recommend to get the vaccine when influenza is already circulating, or it's January or February. Because there is a chance that we can see late influenza, and you can still benefit from the vaccination. This year, the influenza vaccine contains two influenza A, and two influenza B strains in the case of the quadrivalent.

So we have two types of influenza vaccine. One that is trivalent-- it has two A and one B strain, and quadrivalent, which has two A, and the same B, but adds one additional B strain. So what I have listed here is just the strains that are included in this year's vaccine. And make a note that they are the same as the vaccine that we had in the previous year, with the exception of the A H1N1, which is now a strain that is different from the one that caused the 2009 pandemic, and had been included in the vaccines until now. So this is the one change. As a comment-- preliminary data shows that the match of the vaccine with the circulating strains is expected to be good this year for the predominant strain, which is your H3N2. There is a lot of discussion about the effectiveness of the seasonal influenza vaccines. What is effectiveness? It means, how good is the vaccine in preventing influenza illness? And in the case of these data, it's based on medically attended and confirmed influenza. So it's laboratory diagnosed, medically confirmed, and medically diagnosed influenza. And so the effectiveness varies year to year. And we know that it's a vaccine that is not 100 percent effective. We hear oftentimes that you received the vaccine and you still get the flu. This is because there are many factors that are affecting how well the vaccine works. I've talked already about the match of the vaccine with the circulating strain.

This varies year to year. But also keep in mind that your health status is going to be a factor. So people who might not have a good immune system, or reasons why their immune system won't be able to allow them to have a good response, will not have the best effectiveness. Age is another factor. Young children and older individuals may not respond as well to the vaccine. And then we also talked about the timing of vaccination in relation to the season. So if you take your vaccine too late, then the vaccine is not going to show effectiveness for that year-- especially as the majority of people take the vaccine too late. So you see that it varies. And this is for the last flu season since 2004 to 2017. But in general, it is expected to be at least 50 percent to 60 percent for the most part. So there's a good chance that you have protection against influenza. Most importantly, though, is what are we trying to do when we try to protect against influenza? It's not necessarily from catching the flu and having a mild illness, but actually from the complications of influenza. I want to show you this particular study that was recently published, that shows that in terms of effectiveness, the vaccine is very good at protecting children against death. And this was looked at by the CDC, in children six months to 17 years, for the seasons of 2010 to 2014.

And when you compare how many of the children died who had received or not their vaccine prior to the onset of their illness, the effectiveness in this case was about 65 percent. And this is particularly true in children that have high risk of underlying conditions, but also for those without underlying conditions. And similar data has been shown for adults, and also in terms of decreasing hospitalization. So we are protecting our patients' against the most severe types of influenza and their complications. All right. We are going to go through a series of polls. And so, let me ask you to just go over the recommendations. Again, you can start answering right now. Children can receive the flu vaccine either as a shot or as a nasal spray during the 2017-2017 influenza season. Please let me know if you think this is true, false, or if you're not sure, that's okay. I'll give you a few seconds. Very nice. We'll go ahead and skip to the results. And let's see. So most of you -- at least more than half -- believe that it is a false statement. That it is not true that children can receive the flu vaccine either as a shot or a nasal spray this year. And some of you think that that is true. Let's look and see what the correct answer is.

It looks like it's still polling. The answer is that actually it's a false statement. And the reason is because the live vaccine should not be used actually in any setting during this season 2017-2018. As a matter of fact, this is the second year in a row that the live nasal spray vaccine is not recommended for children in the United States. So let me give you just a little bit of background as to why this happened. The effectiveness of the vaccine is looked at every year by different studies. And particularly, there is this Vaccine Influenza Network from the CDC, that looks at the effectiveness of the vaccine year to year in different populations. Data from the 2015-2016 season, showed that the effectiveness of the vaccine that year was different if you compare the live vaccine-- which is the nasal spray-- and the shot-- which is the injected or inactivated vaccine. What you see in this graph is a line in the middle -- the dotted line -- that has a zero. Anything that is close or below that zero line, shows no effectiveness or decreased effectiveness. And so in the different subgroups that you see, overall, for that season, the vaccine effectiveness was about 52 percent. For the different subtypes, A or B, it was about the same, 48, 50, 53 percent. But when you look and compare the inactivated vaccine, which is vaccine type IIV, it's the shot, compared to LAIV -- which was the intranasal vaccine -- a huge difference.

60 percent for the shot, and only 5 percent effectiveness for the live intranasal vaccine. And then you see those numbers below for the specific strains. Unfortunately, the live vaccine did not show effectiveness that year. But also in at least three seasons prior to that one. Therefore, in 2016-2017, the recommendation was that we could not use it, because there was no guarantee that it would be able to protect infants and young children given these data. And the same holds true for this current season '17-'18. So the only vaccine that we have available is the shot. And there are many of them out there. There's no concern with availability of vaccine. But I just wanted to make sure that we remember that this is the case at this time. Another question. In terms of recommendations, let's talk about a particular case. You have an 18-month-old -- Jill -- who received two doses of the flu vaccine last year. How many doses of the flu shot does she need this season? Does she needs zero? She need one dose? Two doses given two weeks apart, or two doses given at least four weeks apart? And I give you just a couple of seconds. All right, let's go through the results. So the majority of you have said that she would require one dose. Let's look at their answer. Some of you said two doses four weeks apart, which would be the correct interval. But the answer is actually one dose. And let's review why. She's 18 months. She's received two doses last year.

The recommendations for the number of doses of influenza vaccine that children need to receive depend on their age, and also on prior vaccination history. So for young children six months to eight years, who actually have a lower response in general to vaccination, we recommend that they receive two doses of influenza vaccine if it is the first time they're ever being vaccinated, or if they have not had complete vaccination before, and that was their first season. So if a child has received two or more total doses -- either in the previous season, or any time before the previous season for the older children -- of any trivalent or quadrivalent vaccine -- in this case, prior to July 1st, 2017 -- which would have started the season for this year -- And if they have received those two or more, then they would only get one dose -- which is the case of the child that we discussed. If they have not received at least two total doses, or you don't know, then they should get two doses with an interval of four weeks, as we mentioned. And this is because, again, you need that much stimulation-- two doses-- to be able to have enough protection. So young children will take at least six weeks to be fully protected. Then another reason for young children to be vaccinated as soon as possible, when the vaccine becomes available. Children nine years of age and older. And all adults only need one dose. I would like to ask you another question, and this is to review the recommendations. So for whom is influenza vaccine not recommended? Health personnel, pregnant women, women who are breastfeeding, infants under six months of age, contacts of healthy children less than five years, or contacts of high-risk children.

I'll go ahead and give you a few seconds. All right, I think we're getting to a good number of responses. Let's go to see the results. Wonderful. So the majority of you correctly identified infants under six months of age. And that is the case, as we mentioned before, because we just don't have a vaccine for those. And everybody else listed in those categories needs to be vaccinated. So these are the answers. And here's one more question that relates to updated recommendations. So you have a three-year-old, Jack, who is allergic to eggs. And his parents are concerned because they heard that flu vaccine is made in eggs. What do you tell them? He should not get the flu shot because of the egg allergy -- He should only get the flu shot that is egg-free -- They can tell him that the egg-allergic children can get the flu shot-- or that the flu shot must be given by an allergist. I'll give you a few seconds for this one. Okay. I'm going to go ahead and jump to the results and see what you said. All right. So a little bit more varied responses on this poll. The majority of you have said that you would allow this egg-allergic child to get their flu shot. S

ome of you said, okay to give it, but only if it's egg-free. And there's an equal number-- about-- that would say not to give it, or to give it by an allergist. So let's look at what the correct answer is. Actually Jack should be able to get his flu shot, because egg-allergic children can get the flu shot. And actually, they should get it like any other routine vaccine that is available out there. Why is that? This is an updated recommendation based on evidence, practice, and also review of the literature. So this is actually the second year this recommendation is in place -- that allergic children can receive the flu vaccine. This is after review of many studies -- about 28 studies -- that included more than 4,000 egg-allergic children and adults. So this is egg-allergic people with known diagnosis of egg allergy. As you can see, more than 600 of them with severe allergies, where no serious allergic reactions -- either respiratory distress, hypertension, anaphylaxis, et cetera-- were seen after receiving the flu vaccine. As a matter of fact, these studies identified that these individuals -- even though they have egg-allergy -- don't have a higher risk of having anaphylactic or severe allergic reactions than the population in general would have. And as such, the American Academy of Pediatrics and CDC have agreed that all children with egg allergies can receive their flu vaccine with no special precautions then those recommended for routine vaccines. So no need to send them to the allergist either.

All right. I'm coming down to my last poll. And in this one I'll be interested to see if you received the influenza vaccine last year. Now, I don't see this one showing an option to give you answers, but I would like to make sure that you tell me, or think about it, if you received it. Or if you didn't, why that didn't happen. Because you don't think you need it, or because you're worried about side effects, or you didn't have access to the vaccine. All right. Many of you are answering. Thank you so much. So let's talk about why it's important to get your vaccine. Let's think about the patients, and the children that we care for. So this is the concept of cocooning. What is that? It's a strategy that aims to protect children from disease by vaccinating their caregivers, and actually other contacts around them. So if you get vaccinated as a caregiver, you have less risk to get an infection, which means you are less likely to expose children to your infection, and you have less children who get disease, and who get to spread the infection themselves. Think about the fact that many of them cannot be vaccinated, or don't respond to the vaccine, or might not have been vaccinated on time to get protection. And then when you look at what would be our responsibility, this is a study that looked at a simple question -- Should professionals caring for children be vaccinated? And in the eyes of the public, more than 90 percent of people think that nurses, doctors, and child care providers actually have an obligation to be vaccinated. So perception is very important, and that's an expectation here.

This is also important at the level of the country. And there's legislature that has been already initiated, particularly here you see, in the state of California, where as of 2016, they would prohibit with this bill people who are employed or volunteering at daycare centers or family care homes to work if they have not received vaccinations against flu pertussis and measles, which are contagious communicable diseases. And another point about this, the American Academy of Pediatrics also mentions issues regarding to exemptions or non-medical immunization exemptions for child care and school attendance, indicating that non-medical exemptions to immunization requirements are actually problematic, because unfortunately, they put individuals at risk in the communities. So this is just a small graph to show you certain states or places where day care vaccination is mandated, and it's just a few in the country as of January 2015. So I will just finish my presentation by briefly telling you about another option, which is the use of anti-virals. We do have options. Once we have influenza circulating, and, unfortunately, we catch the flu, there is anti-viral treatment with now three neuraminidase-inhibitor drugs. Oseltamivir, Tamiflu, Zanamivir is called Relenza, and Peramivir, which is a new and intravenously administered drug and neuraminidase-inhibitor.

All three work against influenza A and B, and they're used for treatment or prophylaxis in the case of Tamiflu and Relenza, but not the peramivir. And they're recommended that for young children, especially the oseltamivir, starting at any age. So we have recommendations in place from the CDC to indicate that anybody that is treated with anti-virals can actually shorten the duration of their illness and fever, and also have a decreased risk of complications from influenza, especially pneumonia or ending up in the ICU with respiratory failure. It also reduces the risk of death of hospitalized adults, and it can shorten the duration of hospitalizations in children. So the recommendations are simple. They are to use anti-virals as early as possible for any patient who has either confirmed or suspected flu. One doesn't need to wait for confirmation. And if a person who is hospitalized, or they have severe, complicated, or progressive illness, or they have one of those medical underlying conditions, that puts them at high risk for influenza. And then people who are previously healthy and have the flu-- even if not considered in a high-risk group, and they have influenza, based on clinical judgment-- physicians can decide to treat them, if treatment can be started within 48 hours of illness. So with that I will end my presentation, and we'll pass it on to Dr. Shope, who will talk to you about prevention in your settings.

Dr. Shope: Thank you. Okay. Thank you very much, Dr. Munoz. That was a fantastic presentation and overview of influenza. My job is going to be to discuss how you apply all that information to the settings in which you care for children-- in early education and child care settings. Just to reemphasize, you care for the most vulnerable population. As you saw, older people and younger children are at higher risk of influenza complications from death, hospitalization, school absences, doctor's visits, and ear infections, are all complications that young children get from influenza. And then especially vulnerable children are those under six months, who are too young to be vaccinated. We try to prevent flu in the community oftentimes by using prevention methods. Some of these are called non-pharmaceutical interventions, or MPIs. And that includes keeping people separate from each other -- something called social distancing -- and hygiene, and respiratory etiquette. And as you all know, in your setting it's difficult to teach young children how to do this effectively. Especially keeping themselves apart from each other. That's exactly the opposite of what they want to do.

Another technique or tool that we have is exclusion. And again, we don't want to exclude everybody who has the common cold. We want to exclude people who have influenza. We'll talk about how that is a little difficult later in my talk. And using infection control methods to try to prevent the spread of flu is challenging, because the flu is spread by droplets that are expelled into the air by coughing, and sneezing, and touching things. And that makes it challenging. The other issue, that Dr. Munoz also addressed, is that children bring influenza home to families, and spread it into communities. So you're really at the epicenter. You're in an extremely important position taking care of young children in early education and childcare, in terms of preventing flu from spreading into the community. So let's talk a little bit about what you can do. Let's start with a case. You're the director of a child care center. And last year, during the flu season, two infants from your center were hospitalized with complications from influenza. Fortunately, they recovered, and didn't suffer any long-term health problems. This experience made you determined to do the best job possible to address this season's expected influenza outbreak.

So what can you do in your settings? Let's discuss that. Some possible options that you can use are to immunize, use infection control and prevention, and use exclusion-- denying admission of an ill child or staff member to a facility, or asking them to leave if they're already present, and they develop symptoms later. So let's go to a poll here. And I want you to answer what you believe the most effective method of those three is for preventing influenza in child care settings. I'll give you a chance to answer those items. All 431 of you. Click away. Okay. So I'm going to skip to the results. I see the majority of you have chosen immunization. And then a large portion, infection control and prevention. And a much smaller proportion, exclusion. And that is fantastic. The number one method is indeed immunization. Less effective, infection control and prevention. And probably less effective also is exclusion. We're going to talk about that in detail here. So just kind of summarized that there. Let's go into more detail. So influenza vaccination effectiveness, as you saw in the slide that Dr. Munoz presented, varies by season. But let's think about, what are the chances of getting influenza without immunization for children? And a lot of us might not realize that as many as half of children show evidence in their blood that they've been exposed to influenza, and develop antibodies against influenza. That means they had an infection. But not every child who gets an infection gets sick.

It's probably only about one out of four in any given flu season. But again, that varies by the flu season. Now, getting the immunization is normally around 50 percent to 60 percent effective. I noticed that one audience participant submitted a question-- if it's only 50 percent effective then why give it at all? Well, the answer is that any measure of protection reduces the chance of the child getting influenza. And the chances of preventing mortality -- death from influenza -- is even better than 50 percent. So the main reason we want to prevent influenza, is to prevent hospitalization and death, the serious complications. And the vaccination actually does quite well with that. The intranasal vaccine, as was described, used to be even more effective than the shot. But over the last 40 years, that has not been effective. And we're working really hard to try to figure out why, and hopefully bring that back again. Because a lot of parents and children preferred the spray rather than the shot, obviously. So even though the vaccine isn't 100 percent effective, if you get vaccinated, you're much less likely to catch the flu, or get seriously ill. That is the bottom line. So, what's going on in the country right now? Well, we know that in 2016, we did a study of randomly-selected US child care center directors, and asked them whether they required influenza vaccine for children.

And only 24 percent of directors required the flu vaccine. And more than half of the centers did not even track whether children receive the flu vaccinations. For the adult caregivers who worked in those centers, only 13 percent of the directors required the flu vaccination. And again, more than half did not track the flu vaccination. So that was whether the directors required the vaccinations. But a 2012 study actually looked at how many child care providers actually received the flu vaccination -- and that was only 22 percent. So it's pretty low. Now, I noticed a lot of you responding to Dr. Munoz's question said yes. But there were some nos in there, too. So hopefully, through the rest of this talk, we can convince you of some of the reasons why you should get that. All right. So let's transition now to the next issue, which is infection control. And in order to understand infection control, we have to understand how influenza is spread. So I'd like you to answer this question about how it's spread-- from dirty hands, from diaper-changing, particles that float in the air and go into the lungs, droplets that land on people's faces, or by touching contaminated surfaces and then the face? Okay. I see a lot of you are answering.

Okay. Let's skip to the results here, and take a look here. Okay. So we have not as many people saying from dirty hands from diaper changing.

The most of you are responding that floating in the air and going into the lungs. And then a little bit less-- droplets landing on people's faces. And lots of you, from touching contaminated surfaces. So the answer's actually C, is the most common way. Large droplets that spray out of people's mouths after a sneeze or a cough, travel about three feet and normally fall to the ground. But in child care settings, obviously the children are not three feet away from each other. And often it will land in their eyes, nose, and mouth. And that's how an infection is caused from influenza. And also, sometimes those droplets fall onto surfaces, and people touch them with their hands, and then put them in their eyes, or nose, or mouth. Floating in the air and going into the lungs. That's something that is called airborne spread. And that's more common with measles, but not influenza. Influenza only hangs in the air for about three feet, and rapidly falls to the ground. And then dirty hands from diaper changing is not a method in which influenza is spread. So, here's just a visual of what a sneeze looks like with the proper photography. And you can just see those particles flying through the air. And you can just imagine if a child is sitting in that impact zone, how quickly that child would become infected.

Okay. So the methods that we have to try to prevent infection are, as I mentioned earlier, hand hygiene, surface cleaning, sanitizing and disinfecting, coughing and sneezing etiquette-- trying to teach children to cough or sneeze in their shoulder or their elbow. And these recommendations are covered extensively in Caring For Our Children, third edition, which is available online. It's free. It has a searchable database. You can plug right into that link, and look those up yourself, or any other questions for that matter. And then we also have these recommendations in our publication Managing Infectious Diseases and Child Care in Schools. This is available for purchase. It has the same recommendations as Caring For Our Children, and what people find appealing is that it has quick reference sheets that can be passed out to parents, and go over how to handle a variety of different infectious diseases, including influenza. In that same survey that we did in 2016, we learned that about 3/4 of all licensed child care centers use this reference. So we were really happy about that. So let's try this poll here. To what extent can we reduce respiratory illness in group child care using excellent infection control methods? You have a choice between 100 percent, 75 percent, 50 percent, and 25 percent. You saw that immunizations were at the upper end -- probably around 50 percent to 60 percent influenza immunization. Less people are responding.

Come on. Push those buttons. Don't be frightened. Okay. Slowing down here. So let's look at the results. So we see that 5 percent of you said 100 percent. 45 percent of you say 75 percent reduction. And about 40 percent of you say 50 percent reductions. And only 9 percent say 25 percent reduction. And so, I would have to say that you guys are a little optimistic. So the answer is, unfortunately, 25 percent, as best we can tell from some research studies. And I'll show you those here. So there is definitely a benefit. But unfortunately, it's not as great as we would like for respiratory illness, and specifically for influenza. Now when kids get older, when they're school-aged, by teaching them hand hygiene respiratory etiquette, they actually do pretty well. And they can reduce the spread of illnesses by 50 percent respiratory illnesses. But in the younger age group, the benefit is a lot less. And one study showed that there was at the upper end, around 35 percent benefit in reduction of influenza-like illness when hourly hand sanitizer was used.

Now, all of you know, that's pretty difficult to wash your hands, or do hand sanitizer once an hour. But there is a little bit of a benefit from that. And then another study showed a benefit that was on the smaller end of that range. But it only applied to children under two years of age, and not children two to five years of age. And so we also care about children getting so sick that they can't attend-- school absence. And really intense research regimens, that try to teach everybody the best infection control regimens, only showed a 10 percent decrease in absence. So that's a little discouraging. But it still should be done anyway, and let's talk about this. It's definitely not as effective as immunization, but I don't want you to stop doing it, because it actually helps prevent the spread of other infections-- especially diarrheal disease, which are more easily spread from contact on surfaces. And so, you may ask yourself, why is it that it doesn't work so well? Well, remember, it's spread by droplets. There's nothing we can really do to prevent those sneezes and coughs from going directly into other children's faces. And so I think that's why it's a little less effective with most respiratory diseases, including influenza. So you shouldn't change your practice of infection control during flu season. You should consider intensifying your hand-washing and alcohol-based hand sanitizer use. But realize that there's a limit to what you can accomplish. And don't feel guilty. You're doing the best that you can.

Okay. So now let's move to exclusion. And we'll address this with a case. So we've got a teacher or caregiver in a toddler room, sees reports in the media that it's flu season. It is right now. She sees that Susie has been flushed. She's laying on the floor for the past hour, and has a cough and runny nose, and she wants to be held all the time. The caregiver takes Susie's temperature, and it's 104. And when Susie's mother is called, she's frustrated. She has to come pick her up. And when she arrives, she notes that Susie's classmate Bobby also has a runny nose. And says, why doesn't he need to be excluded, too? Bobby, on the other hand, is playful and running around with the other children. So this brings up another poll. Why is Susie being excluded? And there are several potential answers. And you can pick more than one. I won't be able to tell if you pick more than one, but go ahead and click as many as you think is right. She has a runny nose and cough. She has a fever. She's requiring too much care. She can't participate in activities.

She has a fever and respiratory symptoms. All right. Answers are streaming in. Very enthusiastic response to this question here. All right. So let's take a look. So what we see is that about 17 percent of you said that she needs to be excluded because she has a runny nose and cough. About 2/3 say, because she has a fever. About 1/4 say she's requiring too much care. And 57 percent, because she can't participate in activities. And then the final answer-- 2/3 said, because she has a fever and respiratory symptoms. So this one's a little more complicated. The three bottom ones are correct. She's requiring too much care, and she can't participate in activities, and also, that she has a fever and respiratory symptoms. And we will discuss why the first two don't necessarily apply. Okay. So she is excluded because she's being held all the time. That just requires you to provide care to her, and you can't provide the necessary care to the other children that you're charged with. It starts to affect the ratio that you have. And she can't participate in activities. That's a rule no matter what the condition is. Any children that have either of those first two need to be excluded. And also, if she has a fever with respiratory symptoms. A child who has fever alone doesn't necessarily need to be excluded. But you usually won't know that, because you wouldn't check a temperature on a child unless the child was displaying some signs of illness.

So usually, when you're detecting a fever, there's also a sign of illness. That's what prompted you to check the temperature in the first place. On the other hand, Bobby's acting normal and doesn't have a fever. So he doesn't need to be excluded, even though he has respiratory symptoms. Now, a lot of you answered that the reason why we exclude is to prevent the spread of disease. Well, with influenza, we're not solely excluding for the prevention of spread. And as Dr. Munoz pointed out earlier, children with influenza virus are infectious a day before the symptoms develop. And they may shed that virus for up to two weeks. It could be present in their nasal secretions and other body secretions. The other issue is that a lot of children are infected and infectious, but they don't show symptoms. Either it's just before they got ill, or it's after they got ill. And even potentially, some children who get infected, but don't develop symptoms, may actually still be able to spread the virus to other children. So we don't actually know if exclusion reduces the spread of influenza. And the other issue that makes influenza and exclusion challenging, is we don't exactly know who to exclude. We can't always tell who has influenza. Sometimes we worry about influenza being really serious, resulting in hospitalization and death. But influenza can be mild in some cases. So it can look like the common cold. And in many cases common cold viruses can actually be very severe, and children can be quite ill from those. So we can't tell just by looking at children who has influenza.

In fact, even at the peak of influenza season, when we test people who have fever and respiratory symptoms, about 3-to-1 ratio, actually have other viruses other than influenza. So that's another challenging thing. They look exactly like they have influenza. They have a high fever and cough, but they actually have a different virus. And so we can't exclude everyone who might have influenza, like Bobby, if he's not requiring extra care and he's participating adequately in activity. So which children should be excluded? Like I said, the first two reasons apply to any condition. If a child is not participating in activities, and requiring too much care, or children with fever and respiratory symptoms. And there is some truth that the amount of the flu virus is greatest in these children. And then that amount goes down significantly as their symptoms start to get better. And then there could be other exclusion criteria that you might find in managing infectious diseases. Like really fast breathing, for example, in a child who had influenza. So this approach, we think, may reduce some of the spread of influenza. But we don't know for sure. There's no research that shows that exclusion works for influenza. So after considering the effectiveness of the various options for controlling flu, you decide that you're going to really focus on immunizations this year. So you develop an influenza vaccination strategy for adult caregivers and for children. And we'll discuss how to address that. Some different strategies you can use -- I really think we need to start thinking about influenza vaccination as a requirement.

Dr. Munoz covered all those advisory committees and organizations that go into agreeing that the flu vaccinations should be given. They use the word "recommend", and they don't ever use the word for any of the vaccinations "required." But the point is that the influenza vaccination is recommended just as much as the polio, the measles, the mumps, rubella. Everything else that everybody has no problem giving. It's the states and their legislators that turn these recommendations into requirements. But that takes a while. As we see in our own state and federal governments, things move very slowly, and they're not necessarily based on scientific evidence. So I want you to feel empowered that you can require these vaccines if you believe in it. There is no law against requiring a vaccination for children and for caregivers in your program, and you don't need to wait for the state to do that. Now, as far as requirements in adult caregivers, I use the argument that health systems require influenza vaccine as a condition of employment. The reason why they do this is because people are taking care of a vulnerable populations, those who are hospitalized, whose immune systems may be compromised, who are susceptible to disease. Well, child care providers are in the same situation. They have that vulnerable high-risk population. When parents put their children in your care, they trust that their child will be safe.

And a child care provider could inadvertently spread influenza to a child. And we don't want that to happen. The best way for that to not happen is by immunizing. We have a duty to protect these children, especially those under six months. And we saw the California law. There's also a Rhode Island law where flu vaccination is required. Many states have language in there, they recommend. But that language doesn't say "require" for influenza vaccine, yet. But that may be changing. Just like all these other vaccinations started as a recommendation, ended up as a requirement. Again, I encourage you to develop your own rules, and don't wait for the state legislatures to pass these laws. What's out there about requirements for influenza vaccine in children? There are several states -- Connecticut, New Jersey, Ohio, and Rhode Island-- and New York City briefly had the law, but it went away. Again, go for it in your programs. There's no reason why you shouldn't do it. Some other strategy you can use. You can use the financial argument. I think it's an important one, and some people resonate to this argument. If you get the flu, again, you're not going to get it every year -- but if you get it, you're going to be sick. Maybe five days of fever. You'll lose wages. That's important. And then think about your colleagues. When you're out because you didn't get the flu vaccine, they have to work harder, do the same amount of work with less people.

That's not something you want to leave to your colleagues. Now children, when they get flu, may be sick also for five days. And they have to be excluded. When they're excluded, somebody has to take care of them. They have to be taken care of by adults. The adults lose wages. So the other issue to consider is that children can bring flu into the home, and more school absences for other children in the home. More lost wages. Financial argument I think resonates with some people. We can also use the social consciousness argument-- that you need to protect the vulnerable children for whom you care, for adults. And you don't want to bring influenza back into your family. You're exposed to a lot of kids who have a very high chance of having influenza when you're taking care of young children. And then for children, we want to protect them from bringing the disease into their homes. What if they had a grandparent who was elderly or somebody who was being treated for cancer, for example. So these are all considerations that people need to think about. It's not just yourself-- the individual receiving the influenza vaccine-- it's others around you. We also have to consider what are the health beliefs and barriers, and top reasons that adults and children don't get influenza vaccinations.

And I've divided this up into three general categories. But people oftentimes believe that healthy people don't need it. They never get the flu. They're unlikely to get sick from the flu. And they're not at risk for the flu. And again, you've seen the numbers. It's about one out of four every season. So there is a little bit of truth, but you're playing with fire there. It's a game of Russian roulette. There are people who infrequently see physicians infrequently receive the flu vaccinations. So that can certainly contribute. They may not have time, or they may not get a recommendation from their physician. And certainly that's true if they don't actually see their physicians. Many people are afraid of vaccine side effects. They they're afraid they might get the flu from the vaccine. They don't trust doctors. They think the flu vaccine is a secret plan by the government. They're afraid of needles. So these are all things that we need to address when we try to increase flu vaccination rates. And so there some general strategies that I've listed here, that you can use in your setting to try to increase influenza immunization rates. First is obviously education about all those beliefs that you just saw. Second, is to improve access to immunizations. And then the third, to the extent possible, we want to try to eliminate costs or provide incentives. So let's go over those.

There are some excellent resources. You don't need to research all this stuff yourself. You can just go to these websites by the CDC and download information. Pass it out to your staff, and to parents at your programs. There's even a quiz there at the third bullet. It's fun to do, and it can increase knowledge. You can put up posters. All these materials basically try to address the common beliefs that people have. And hopefully, people realize this is not a secret plot by the government. Now there are also specific resources for parents and caregivers of children in child care. The AAP has a letter for parents. The AAP also puts out a messaging series available at that link, that has information about influenza as the season goes on. Moving from education to access. Giving on-site immunizations is fantastic if it can be arranged. It does happen. I know it's not easy to arrange anything like that. So you're dealing with different health insurances. You're dealing with -- does the franchise that you work under allow this type of thing? But I just want you to understand that it's possible, and it should be explored. Health departments sometimes do it. Child care health consultant could sometimes organize a program. And then there are actually companies -- one of which is called Passport Health -- that actually bring the immunizations to your site, and handle the entire immunization process for children and adults. We want to make it convenient for staff to get it if you can't do it on site. And so you want to find out local sites that they can go to get it, in addition to their own primary care provider, which would be the optimal site. And you want to be sure that they have the time off to get it, during the work day, during office hours.

Basically, you just want to make influenza vaccine a part of routine habit. So in terms of costs and incentives, studies show that employers save money by providing influenza immunization. And some businesses pay for the vaccine, so it's free for the employee. Again, I know that many of you are caregivers and directors, but you don't necessarily have the control over whether this gets provided for free for employees. But that's something that should be explored. Things as simple as a $5 gift card, has been shown to increase influenza immunization rates. And for children, consider providing a book to children if they're vaccinated. This is a small cost, but it could be a simple incentive that could improve your immunization rates. Studies show that flu immunization rates can increase to 50 percent to 60 percent from around 20 percent for caregivers, if the vaccine is offered free and on site. So this is a huge increase from what we know from a few studies, that the caregiver rate is only around 20 percent. So definitely worth exploring.

Okay. So I definitely would love it if you guys could share in the chat box anything you've done to increase influenza vaccination in your program. We're looking for good examples out there to try to use as models for other programs. Summarize. The take home point about seasonal influenza is that it's the most common cause of vaccine preventable deaths in children. And children spread the influenza to caregivers, families, and communities. Immunization is your best technique. Infection control is also important, but not as good as immunization. Exclusion should be used when it's needed, but it's probably not the best way to reduce the spread. And you and child care programs have an incredibly important role and opportunity to improve immunization rates. And you should have a seasonal influenza plan that should be reviewed and updated annually. And we'll have examples of that at the end of this talk. But right now I want to transition to Dr. Munoz, who's going to talk about pandemic influenza, and how that's different from seasonal influenza. Dr. Munoz?

Dr. Munoz: Thank you Dr. Shope. This is outstanding. And we will take just a few minutes to talk about how is it different. How is pandemic influenza different from seasonal influenza? And I think that we have had the opportunity to see how this evolved during 2009. But basically, some of the main issues are related to the fact that pandemic viruses are new. Therefore we don't have immunity as a population. Fortunately, these are rare events. While we have seasonal influenza every year, pandemics have happened rarely. And we'll talk a little bit about that. But main concern is that we don't really have availability of a vaccine early on in the pandemic, while for seasonal we have vaccines every year. And with pandemics, everyone is susceptible, not just the populations at risk. Because no one has been exposed to these viruses before, so we all have susceptibility and no immunity. It is rapidly spread, just like the seasonal flu, but it's difficult to stop it, again, because of the susceptibility of the population. Also, when we have a new virus, we might not be able to have a test readily available, or anti-virals that work. Or the number of anti-viral drugs that we have to use might be limited in a pandemic situation, where so many people need to be treated, and we have a lot more hospitalizations and deaths that could occur. So just to give you a little bit about what leads to a pandemic.

First, the only viruses that can cause pandemic are the influenza A viruses. This is because they have the ability to mutate, or to have more opportunities for changing their genetic makeup through mixing and combining in the environment. So flu viruses actually come from nature. They come from birds. The majority of the viruses that have caused major pandemics come from birds. And not all the viruses that are circulating in birds can cause human disease. You see that they're classified based on the surface glycoproteins that we call H for hemagglutinin and N for neuraminidase. And there are many types-- at least 18 H types and 11 N types-- but only a few of those infect humans. When the new virus is developing, or it arises, it's a novel strain. It has a new combination that humans have never seen in their genetic makeup. And they're usually transmitted initially from animals to humans, causing rare disease. We are seeing this right now actually, in China, with a virus called a H7N9, that fortunately, has not gained the ability yet to be transmitted from human to human. And therefore, it's possible to somewhat contain the transmission by avoiding contact with the animals that harbor this virus. But when it happens that the viruses get the ability to go from one person to another-- just like we saw in 2009 -- then it can spread and cause a pandemic, which is basically an epidemic that covers the globe.

And it's very rapidly progressing as you can see. So here are some few facts. First of all, let me tell you, we are in the 100th year of the first pandemic. This is 2018. The first big pandemic that we know of occurred in 1918, and that was an A/H1N1 virus. That actually, has been the worst pandemic that we've had. It caused 1 percent to 3 percent mortality of the world's population. If you look at numbers of mortality in the world-- especially also in data from the United States-- shows a decrease in mortality because of public health, and water, and good interventions like that. But then during 1918, a sharp peak of deaths occur because of influenza. So there's been a total of four times when we've had pandemics. That was the first. There were two others-- one in 1957, and one in 1968, when we went from H1 to H2 and then H3 respectively. And then of course the 2009 H1N1 pandemic, which was relatively mild, when we talk about mortality, compared to the terrible one in 1918. Importantly though, we don't know how severe the pandemics will be. And first, again, it's not a matter of if it will happen. We know pandemics will occur, because this natural process in the environment is happening all the time. So it's not if, it's when. Whenever the next pandemic occurs, we just won't know how severe it is until it happens.

And of course we worry about it, because it affects disproportionately healthy people, young people, and that the methods that we have to reduce its spread are relatively limited, because, as we have seen, we have to rely on the distancing, and social etiquette, and the medications and vaccines that might take some time to have available at the time. And so, just a few issues related to early education and child care. As you know, it's difficult to enforce hand hygiene, respiratory etiquette, and distancing in young children. And if we have a pandemic, it would be important to know that there might not be enough medications-- the vaccine won't be available early on-- and that as child care providers, you will have a difficult time keeping children and keeping your business open. So closures will be likely necessary, because that would be one way of containing the spread of this virus, that is so easily transmitted. So one must plan ahead. Dr. Shope will tell you then, how it's best to plan for a pandemic. Thank you.

Dr. Shope: Thanks. So I think a good way to think about pandemic influenza planning is how you think about disasters like an earthquake, or a tornado, or a fire. This is a plan that you need to have, and you need to review periodically. Whereas seasonal influenza planning is something that we do every year, and it should be routine. So obviously, why panflu planning is needed is it's an emergency. It can affect people's lives, and have big, adverse consequences. And preparing ahead is really important. What's the key difference, I think, is that in the worst-case scenarios, public health officials would tell you to close your center. And so imagine what life would be like if your center was closed, or was going to close, or possibly going to close. You have to be able to communicate to all the parents. The parents have to have alternative care arrangements. They're going to need to know when they can come back. And so these are things that have to be planned for before it actually occurs. So some things that you need to think about is who's in charge of this.

So one person at the program needs to be in charge of it. Where are you going to get your information? We have some resources for you to think about. The closure issue is really important. Short of closure, the recommended exclusion times for respiratory illness may increase. And that could affect parents' ability to work, and the number of children that are there, or the number of staff that could come in to take care of the children. The communication plan is essential. Schools and universities used websites, they use social media, news media, radio, and they announce delays and closures for weather and other issues all the time. But typically, childcare programs are small businesses. And they may not have the ability to maintain a website. But we do know from our survey in 2016, that over half of you use social media-- either Facebook or Twitter, or various communications. And this would be an excellent thing to use in a situation like this. Just have to be sure that everybody's plugged in, and could follow any information you want to impart on those channels. And it's an important time for you to take a step back and look at how you communicate with people. If you're doing it all by a pieces of paper when they come to pick up their child or drop the child off, that would not work in a pandemic influenza. What we learned in 2009. fortunately, was not a severe pandemic. But there was a lot of confusion about who was in charge. Whose recommendations should I be following? How long do kids need to be excluded for? At the beginning of that pandemic, until we were able to learn that the mortality rate wasn't as high as we feared. Alternative care arrangements-- Parents need to think about this beforehand. Some of those parents may be critical employees. They may work at a hospital. They have to work if there's a pandemic.

So they have to have a plan, and they have to think about it ahead of time. Okay. So there's a few components that a plan should include. And the CDC is actively working on developing a plan that you can download and use. And it's not quite finalized yet, but-- planning and coordination. You want to define what it is. Who's going to develop this plan? You need to monitor whether there's a pandemic. And I have a link right there. And I just checked it before the webinar, and there is not a pandemic right now. Who has the legal authority to close the program? That actually varies by state. It could be the county health department, state health department. Some states have a child care bureau that's separate from the health department. The Centers for Disease Control. It's confusing. You actually need to ask some questions, and figure this out for yourselves. Identify the key health officials in your community. Collaborate with other child care programs, because it's a little complicated, and you might as well all be working together. Again, communication is key, and we discussed that. Infection control up to the point of closure is going to be really important.

And so we discussed that extensively already. And you have to think a little bit about operations. One of the things we learned in our survey, was that most programs don't have a pot of money to continue to pay employees if closure was to be longer than a week or two. And so, this is another issue that should be talked about in case of a prolonged closure. Okay. So here we discussed that there are some resources. Here's three links that you can look at for pandemic influenza resources. Now these are dynamic. We're still trying to simplify and improve the message. But this is where you can go in the future as you develop your plan. And general information from the AAP on disasters, for child care providers, for preparing for a pandemic, and free online courses for staff who work in Head Start about influenza. And then information about the Center. And at this point, I'm going to turn it over to Sean. We have a limited time for questions. I saw a lot of responses on the chat board, which is fantastic. And we're going to try to answer as many as we can here on the webinar, or afterwards we can answer them in written form.

Sean: That is exactly right. Thank you very much, Dr. Shope. So this now concludes our presentation portion of the webinar. And we'll jump in for some quick questions. But before we do that, I just wanted to quickly let everybody know that the PowerPoint slides and an archived version of this presentation will be available after the webinar concludes. So we did have a few questions come through the chat box feature. Our first person asked, if you don't remember if you got the flu vaccine this year, is it still recommended that you can go in and repeat the vaccine?

Dr. Munoz: I can try to answer that. So hopefully, you remember, because it's a relatively short period of time. But let's say you just don't know, and you might have gotten several vaccines, and you don't know. So yes. It's not a harm to get a second vaccination if you had one relatively recently before.

Sean: Thank you very much. Another person asked, if you currently have the flu, and have not gotten the flu vaccine yet, should you go get the vaccine after you recovered from the flu.

Dr. Munoz: Yes. Let me answer that as well. So absolutely. Actually we would recommend that even if you did have influenza, after you recover go get the vaccine. Because, as we mentioned, there would be an opportunity for other viruses to circulate during the season, and you could still get flu again if you don't have protection against those which vaccines can provide.

Sean: Thank you very much. The next question asks, is it ever too early to get the vaccine in a flu season?

Dr. Munoz: I guess I can do that one, too. Dr. Shope wants to jump in. So the vaccine is usually available in September. That is not too early in the sense that we know that you would have good protection for a good six months. And most of the flu season will be in those six months following that. If you are someone with a weakened immune system, someone old age, someone that has other medical reasons why their immunity might not be as up to par, if you will, you could try to get the vaccination a little bit closer to what we expect the flu season. So that's why we say October, and certainly no later than October, just because we know that the antibodies tend to drop after a few weeks. Nevertheless, one can elicit memory responses. And so there's always a potential for the immune system to be activated even if the antibody levels are not very high. So in some populations, it might be an issue for most people. It's never too early to get the vaccine.

Sean: Thank you very much, Dr. Munoz. Dr. Shope, can you assist us with this question? The person asks, they keep getting people that come up to them with the argument that they've gotten the flu shot before, and they were sicker than they did when they didn't get the flu shot. Do you have any ideas on how to combat arguments like this? Yes.

Dr. Shope:That's a common belief that I see in my practice all the time. And the first thing is that the flu vaccination does not cause the flu. The shot can cause local soreness. You can feel a little achy. A very small proportion of children might have a low-grade fever. But it doesn't cause the runny nose, and the cough, and the high fevers. Those are caused by viruses that actually go in your mucous membranes, and infect the respiratory system. So what's happening is, we're giving the flu vaccine during respiratory season. It's during the season that a lot of other viruses, including influenza, are spreading around. So a certain number of people, right after they get the flu vaccine, are going to get infected by some other virus. And it looks a lot like the flu, but it's not from the vaccination.

Sean: Thank you very much, Dr. Shope. Looks like we have time for one last question. Dr. Munoz, could you help us explain where does the flu come from?

Dr. Munoz: Of course. As I mentioned, actually flu comes from birds for the most part. But when it is able to be transmitted between one person or another, it actually comes from another person. So it's being transmitted among people, and not necessarily from surfaces, or other things like that.

Sean: Thank you very much. And if we didn't have a chance to answer your questions, as we did receive a lot through the chat box, we will respond to you directly after the presentation. But with that, I would like to thank doctors Munoz and Shope for this very engaging, informative presentation. If you want more information, or if you have any additional questions, please contact the National Center on Early Childhood Health and Wellness at health@ecetta.info or call the toll free s 1-888-227-5125. This now concludes today's webinar. Thank you very much. [End video]

Children in group care settings are at increased risk for infectious diseases such as influenza (flu). Seasonal influenza affects many children each year. Simple prevention and control strategies can help to protect children and their caregivers from complications. This webinar will help Head Start staff and early care and education providers take steps to improve influenza prevention and control.

Additional Resources for Preparing Head Start/Child Care and Communities for Seasonal Influenza